Inspection · 2022-03-29
Date
2022-03-29
Complaint Related
No
Licensing Inspector
Lauren Captain
(571) 835-0599
(571) 835-0599
SHSIA monitoring inspection of an approved subsidy vendor to determine compliance with current subsidy requirements regarding the health and safety of children and to promote quality standards for the children in their care.
No
Areas Reviewed
22VAC40-111 Administration
22VAC40-111 Personnel
22VAC40-111 Household Members
22VAC40-111 Physical Health of Caregivers and Household Members
22VAC40-111 Caregiver Training
22VAC40-111 Physical Environment and Equipment
22VAC40-111 Care of Children
22VAC40-111 Preventing the Spread of Disease
22VAC40-111 Emergencies
22VAC40-111 Nutrition
22VAC40-80 THE LICENSE.
22VAC40-80 THE LICENSING PROCESS.
8VAC20-770 Background Checks for Child Day Programs and Family Day Systems
20 Access to minor?s records
22.1 Background Checks Code; carbon monoxide detectors
63.2 Child abuse and neglect
63.2 Licensure and Registration Procedures
Inspector Notes
This renewal inspection was initiated by licensing staff and concluded on 03/29/2022, between the hours of 11 am to 1:30 pm. There were 14 children present (45 points), ranging from infant to preschool-age, with 4 caregivers supervising. The inspector reviewed compliance in the areas of administration; physical plant; staffing and supervision; programming; special care and emergencies; and nutrition. A total of 5 children records, and 5 staff records, and 2 household records were reviewed.
Information gathered during the inspection determined that there were eleven (11) non-compliances with the applicable standards, code, and/or law. These violations were documented on the Violation Notice issued to the program.
If you should have any questions, please call or send an email to charlie.perkins@doe.virginia.gov. Thank you.
Charlie Perkins,
Licensing Inspector
(703) 309-3963
Violations
11Standard 22.1-289.035-B-4
Based on review, 2 of 5 staff files indicated that the Family Day Home (FDH) did not obtain a copy of the results of a criminal history record information check (CRC), a sex offender registry check (SOR), and a search of the child abuse and neglect registry (CPS), (or equivalent registry) from any state in which the individual has resided in the preceding five years before reporting to the FDH.
Evidence -
1. On the date of inspection (03/29/2022), the following staff did not have the proceeding Out-of-State background checks available for review: Staff #4 (from the State of Georgia - SOR check, and a CPS check); and Staff #5 (from the District of Columbia - CRC check, SOR check, and a CPS check).
2. Both Staff #4 (start date - 03/03/2022), and Staff #5 (start date - 03/28/2022) were observed on site on the date of inspection providing care for the children in attendance.
Evidence -
1. On the date of inspection (03/29/2022), the following staff did not have the proceeding Out-of-State background checks available for review: Staff #4 (from the State of Georgia - SOR check, and a CPS check); and Staff #5 (from the District of Columbia - CRC check, SOR check, and a CPS check).
2. Both Staff #4 (start date - 03/03/2022), and Staff #5 (start date - 03/28/2022) were observed on site on the date of inspection providing care for the children in attendance.
Plan of Correction: All required Out-of-State background checks will be obtained. In the future, staff who fall under this requirement, will not start work until all required Out-of-State background checks have been obtained by the FDH.
Standard 8VAC20-770-60-B
Based on review, 1 of 5 staff files indicated that the sworn statement had not been completed.
Evidence -
1. On the date of inspection (03/29/2022), the sworn disclosure statement (SDS) was not available for review for Staff #5.
2. The start date listed for Staff #5 was 03/28/2022.
3. Staff #5 was observed providing care to the children in attendance on the date of inspection.
Evidence -
1. On the date of inspection (03/29/2022), the sworn disclosure statement (SDS) was not available for review for Staff #5.
2. The start date listed for Staff #5 was 03/28/2022.
3. Staff #5 was observed providing care to the children in attendance on the date of inspection.
Plan of Correction: A SDS will be completed by Staff #5.
Standard 8VAC20-770-60-C-2
Based on review, 1 of 5 staff files did not have an original central registry finding on file.
Evidence -
1. On the date of inspection (03/29/2022), a finding of a search of the central registry (CPS check) was not available for review for Staff #2.
2. The start date for Staff #2 was listed as 05/11/2021.
3. Staff #2 was observed on site on the date of inspection providing care to the children in attendance.
Evidence -
1. On the date of inspection (03/29/2022), a finding of a search of the central registry (CPS check) was not available for review for Staff #2.
2. The start date for Staff #2 was listed as 05/11/2021.
3. Staff #2 was observed on site on the date of inspection providing care to the children in attendance.
Plan of Correction: Staff #2 shall be denied further employment until a CPS check is obtained. A request for a search of the central registry for Staff #2 will be sent within 10 days. Once a finding is received it will be shared and reviewed by our Licensing Inspector.
Standard 8VAC20-800-120-B
Based on review, 4 of 5 staff files indicated that not all of the required information was contained within each record.
Evidence -
1. The name address and telephone number of a person to be notified in an emergency was not available for review.
2. Emergency contact information was not available for: Staff #2, Staff #3, Staff #4, and Staff #5.
Evidence -
1. The name address and telephone number of a person to be notified in an emergency was not available for review.
2. Emergency contact information was not available for: Staff #2, Staff #3, Staff #4, and Staff #5.
Plan of Correction: The Assistant/Substitute Provider Record will be completed for all assistants and kept on site.
Standard 8VAC20-800-180-A
Based on review, 1 of 5 staff files indicated that the Provider did not obtain for each caregiver a current Report of Tuberculosis Screening (TB) form (in accordance with the requirements in 22 VAC 40-111-170), every two years.
Evidence -
1. On the date of inspection (03/29/2022), the TB documentation on file for Staff #1 was dated - 12/21/2018.
2. This documentation expired after 12/21/2020.
Evidence -
1. On the date of inspection (03/29/2022), the TB documentation on file for Staff #1 was dated - 12/21/2018.
2. This documentation expired after 12/21/2020.
Plan of Correction: Updated TB documentation will be obtained.
Standard 8VAC20-800-210-A
Based on review, 2 of 5 staff files indicated that in addition to satisfactory completion of first aid training and CPR training, 2 caregivers did not obtain a minimum of sixteen (16) clock hours of training annually in areas relevant to their job responsibilities.
Evidence -
1. On the date of inspection (03/29/2022), Staff #1 had a total of 12 hours of annual training.
2. Staff #2 had zero (0) hours of annual training.
Evidence -
1. On the date of inspection (03/29/2022), Staff #1 had a total of 12 hours of annual training.
2. Staff #2 had zero (0) hours of annual training.
Plan of Correction: All staff will complete 16 hours of training for their current year.
Standard 8VAC20-800-40-A
Based on observation and interview, the Provider did not ensure that the total number of children receiving care at any one time did not exceed the maximum licensed capacity of the home.
Evidence -
1. On the date of inspection (03/29/2022), at approximately 11 am, there were 14 children (48 points) with 3 caregivers on site at the Family Day Home (FDH).
2. The current license posted on site at the FDH states that the approved capacity of the FDH is no more than 12 children at any one time.
Evidence -
1. On the date of inspection (03/29/2022), at approximately 12 noon, there were 14 children on site within the Family Day Home with 3 caregivers.
2. The FDH license posted on site has a set capacity of no more than 12 children at any one time. The certificate issued to the FDH from Arlington County also has a posted capacity of 12.
3. The Provider stated (during an interview conducted on the date of inspection) that he was aware that the FDH was over their number.
Evidence -
1. On the date of inspection (03/29/2022), at approximately 11 am, there were 14 children (48 points) with 3 caregivers on site at the Family Day Home (FDH).
2. The current license posted on site at the FDH states that the approved capacity of the FDH is no more than 12 children at any one time.
Evidence -
1. On the date of inspection (03/29/2022), at approximately 12 noon, there were 14 children on site within the Family Day Home with 3 caregivers.
2. The FDH license posted on site has a set capacity of no more than 12 children at any one time. The certificate issued to the FDH from Arlington County also has a posted capacity of 12.
3. The Provider stated (during an interview conducted on the date of inspection) that he was aware that the FDH was over their number.
Plan of Correction: The FDH will reduce to the set capacity immediately.
Standard 8VAC20-800-770
Based on observation, the weather band radio kept on site at the Family Day Home (FDH) was not battery-operated.
Evidence -
1. The weather band radio on site was crank operated.
2. This radio did not contain a battery.
Evidence -
1. The weather band radio on site was crank operated.
2. This radio did not contain a battery.
Plan of Correction: A working portable battery-operated weather band radio will be purchased for the Family Day Home.
Standard 8VAC20-800-90-C
Based on review, 3 of 5 children files indicated that the Family Day Home (FDH) did not obtain documentation of additional immunizations for children (who were not exempt from the immunization requirements according to subsection B of this section) once every six months for children under the age of two years.
Evidence -
1. On the date of inspection (03/29/2022) the following children did not have a current immunization page on file signed by a physician: Child #2 (immunization page dated - 08/23/2021); Child #4 (immunization page not signed at all); and Child #5 (immunization page dated - 05/10/2021).
2. Based on information on file, all three children were under the age of 2 years on the date of inspection.
Evidence -
1. On the date of inspection (03/29/2022) the following children did not have a current immunization page on file signed by a physician: Child #2 (immunization page dated - 08/23/2021); Child #4 (immunization page not signed at all); and Child #5 (immunization page dated - 05/10/2021).
2. Based on information on file, all three children were under the age of 2 years on the date of inspection.
Plan of Correction: Updated immunization pages will be obtained.
Standard 8VAC20-800-920
Based on review, menus (that included meals and snacks that are provided by the family day home), only reflected what was to be served on the current date.
Evidence -
1. On the date of inspection (03/29/2022), the menu that is available to each child's parent is posted through an on-line program.
2. The information available only included the meal and snack to be served on that day.
3. A paper menu lists in general those items typically served during any given week. This menu is not dated to the specific day of the week or month of the year.
Evidence -
1. On the date of inspection (03/29/2022), the menu that is available to each child's parent is posted through an on-line program.
2. The information available only included the meal and snack to be served on that day.
3. A paper menu lists in general those items typically served during any given week. This menu is not dated to the specific day of the week or month of the year.
Plan of Correction: The FDH is transitioning to the new program called Brightwheel. This program will allow the Family Day Home to display snack and meals to be served over more than a one day period.
Standard 8VAC20-800-960-E
Based on review, infant bottles observed on site were not labeled with the child's full name and date.
Evidence -
1. On the date of inspection (03/30/2022), bottles were observed missing today's date.
2. These bottles were observed in the kitchen; on the counter, and stored in the Family Day Home refrigerator.
Evidence -
1. On the date of inspection (03/30/2022), bottles were observed missing today's date.
2. These bottles were observed in the kitchen; on the counter, and stored in the Family Day Home refrigerator.
Plan of Correction: Parents will be reminded and staff shall serve as the last line of defense ensuring that all bottles are labeled with both the child's full name and date.